Hysteroscopy and other Infertility Diagnostic and Treatment Modalities

Abstract

Keywords:Hysteroscopy, laparoscopy, endometrial polyps, chronic endometritis, pathology, tuboperitoneal infertility

Introduction

Hysterosalpingography can be used for screening uterine abnormalities, and for decades has been safe, simple, inexpensive, and reliable. It is useful for diagnosing uterine polyps, myomas, intrauterine adhesions, congenital uterine anomalies, and can evaluate the tubal status in the proximal, distal, and possibly intrapelvic region. Additionally, reasonable data suggest that hystero-salpingography may be associated with slightly increased pregnancy rates following its use. Whether this is a result of forcing a mucus plug or other lesion out of the fallopian tube, stimulating the fallopian tube, or some other unknown physiologic mechanism, is not clear. Other diagnoses which may be made include adenomyosis or unusual structural defects.

In many countries around the world, infertility has been identified as a public health priority [1]. Approximately 75% of infertile couples have an identifiable cause. The most common causes of infertility are ovulatory dysfunction, male factor infertility, and fallopian tube disease. The remaining 12% of infertile couples are diagnosed with so-called “unexplained infertility” [2]. The main factors of female infertility include tubal obstruction.

Nowadays, tuboperitoneal infertility is a common cause of impaired fertility worldwide. The incidence of postinflammatory changes in the fallopian tubes among patients with a regular menstrual cycle who receive long-term and ineffective treatment averages 33%, with more than half of them having tubal obstruction, 22% having hydrosalpinx, and 2.4% having salpingitis [3,4]. The results of reproductive function restoration after reconstructive plastic surgeries show that the problem of endoscopic correction of tubal-peritoneal infertility factor requires further research in terms of determining the maximum therapeutic potential of endoscopic surgery for various forms of tubal-peritoneal infertility. The value of using endovideoscopy in diagnostics and treatment of various forms of endometriosis is undeniable. In recent years, laparoscopy has also become the method of choice for treating polycystic ovary syndrome. Various methods of surgical correction of polycystic ovary syndrome have been proposed [5,6] but since restoration of the ovulatory menstrual cycle and intrauterine pregnancy do not meet the expected results, more effective methods of endoscopic treatment of polycystic ovary syndrome need to be developed. Thus, literature data and analysis of studies by centers dealing with infertility problems show that despite the use of endoscopic research methods in gynecological practice, diagnostic and operative hysteroscopy and the complex use of laparoscopy have not yet found their proper place in the clinic of female infertility [7,8].

Materials and Methods

The study material consists of a prospective analysis of the case histories of 28 patients who underwent diagnostic hysteroscopic surgeries at the Department of Obstetrics and Gynecology of the Azerbaijan Medical University. Indications for endovideoscopic interventions in 21.4% of cases were primary infertility, and in 38.5% of cases - secondary infertility. The age of the women ranged from 24 to 45 years. All patients underwent various examinations in Baku before admission to the clinic. Outpatient study data showed that all patients, regardless of the form of infertility, received complex anti-inflammatory treatment 2 or more times, hormonal treatment in 22.2% of cases, ovulation stimulation was prescribed in 29.3% of cases, hydroturbation courses (with various drug mixtures) were carried out in 9.2% of cases, and in vitro fertilization in 12% of cases. The average duration of the outpatient study was 2.3±1.2 years.

According to the anamnesis indicators and tests of functional diagnostics of the reproductive system, the results of hormonal examination, as well as Hysterosalpingography (HSG) and Ultrasound Examination (US) of the pelvic organs (if there is a conclusion on the husband’s fertility), the patients were preliminarily divided into 3 groups according to various forms of infertility: Group I - 41.3%) women with Tubal-Peritoneal Infertility (TPI); Group II - 12.2% women with newly diagnosed various forms of endometriosis; Group III - 12.7% women with Polycystic Ovary Syndrome (PCOS).

In the examined groups, 31.7% of the observations were women under 25 years old. The category of patients aged 32-40 years included 8.4% of women. Subgroups were established according to the duration of infertility. The number of patients with infertility lasting up to 3 years in groups II and III was 8 and 10 patients, respectively.

A preliminary diagnosis of endometriosis was made based on a regular menstrual cycle, patency of the fallopian tubes according to hysterosalpingography, and the presence of fertile sperm from the husband.

Hormonal screening revealed abnormalities in 33 cases from Group III: 4 women had a high gonadotropin ratio, 7 patients had a high testosterone level, 5 patients had a high prolactin level, and 9 women had a high cortisol level. It should be noted that data on anti-Müllerian hormone were not presented in this study because pregnancy was recorded almost immediately (in many cases even the following month) after surgery, which made it impossible to conduct this laboratory test. The available data on women who had their anti-Müllerian hormone levels tested are very limited and do not have statistical significance. Diagnostic hysteroscopy was performed with a d-4 rigid hysteroscope. During hysteroscopy, the condition of the endometrium (color, thickness, degree of expression of the vascular pattern, condition of the mouths of the fallopian tubes, synechiae and endometrial polyps, foci of adenomyosis and submucous nodes) and malformations (intrauterine septa) were assessed. Diagnostic laparoscopy was performed on days 5–8 of the menstrual cycle according to the generally accepted method with a set of endovideoscopic devices “karl storz” (Germany). The location, color, size, presence of pathological formations of the uterus (myomatous nodes, adenomyosis), condition of the fallopian tubes, presence of endo- and perisalpingitis, preservation of fimbriae, the ratio of the ovaries and distal parts of the fallopian tubes were determined.

Results

When patients were included in the study, tubal-peritoneal infertility occupied the leading place in the structure of female infertility, in second place was infertility caused by various forms of endometriosis, and in third place was polycystic ovary disease. Using endoscopic and other modern methods of examination in women with various forms of infertility, a comprehensive approach to diagnosis and treatment was developed, which made it possible to make the following adjustments by group: in some women with endometriosis, tubal-peritoneal infertility was added to the diagnosis, so they were included in Group I. Hysteroscopy was performed simultaneously with laparoscopy in all patients.

Synechiae and narrowing of the lumen of the fallopian tubes of varying degrees and their complete obstruction, replacement of areas of focal hyperplasia with whitish thinned areas of the endometrium (cases of fibrosis) were assessed as chronic endometritis, which became the most frequently encountered pathology during hysteroscopy. Signs of this disease of a reliably high frequency were registered in Group I in 6 observations with intrauterine pathology; in the same way, signs of chronic endometritis of a high frequency were also identified in Group III, amounting to 13 observations. Chronic endometritis was identified by certain pronounced signs: mucous membrane with injected vessels, uneven color of the proliferative area, these colors alternate with areas of thinned endometrium with an increase in the vascular pattern, uneven hyperemia and some expansion of the uterine cavity. Hysteroscopic criteria for uterine endometriosis are considered to be point or slit-like single or multiple passages in the form of dark red eyes, changes in the relief of the uterine cavity, an uneven “rocky” picture. Signs of internal endometriosis were registered in group II in 4 cases.

During hysteroscopy, endometrial polyps were noted as oval or irregularly shaped formations, similar in color to the endometrium, protruding on its surface.

Conclusion

Research has shown that in women with reproductive dysfunction, several factors of infertility manifest themselves together, and identification of these factors is possible only by using diagnostic hysteroscopy and laparoscopy, as well as modern visual diagnostic methods.

Acknowledgement

None.

Conflict of Interest

None.

References

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